Elm Crest Retirement Community: Fall Prevention Failure - IA
On September 14, 2025, a certified nursing assistant at Elm Crest Retirement Community and a physical therapy staff member helped Resident 4 transfer to a toilet off the shower room. The two of them got him there together. Then they left him alone.
When it was time to move him back to his wheelchair, the CNA, identified in inspection records as Staff D, went in by herself. She used a gait belt and pivoted him toward the chair. He wasn't far enough back on the seat. He slid down onto the floor.
Staff D told inspectors she wasn't certain, at the time of the transfer, whether Resident 4 required one person or two. "Things change so often," she said.
That uncertainty ran through every account inspectors collected when they visited the facility on November 13, nearly two months after the fall. Another CNA, Staff C, said the resident required one-person assistance for transfers, but acknowledged it could sometimes be two. A family member who said she visits every day described watching staff help him stand with a walker and turn toward a bed or toilet, with one or two people assisting depending on who was working that shift.
The Director of Nursing told inspectors she had not been working at the facility when the September fall occurred. She acknowledged that therapy had already recommended two-person transfers for Resident 4. That recommendation, apparently, had not made its way clearly enough to the staff moving him.
The facility's own fall prevention policy, undated, states that each resident would be assessed for fall risk and receive care in accordance with their individualized level of risk. Environmental hazards and individual risk factors would be evaluated when building a care plan. Interventions would be monitored and the plan revised as needed.
What the policy describes and what happened in that shower room on September 14 are difficult to reconcile. A resident with a documented therapy recommendation for two-person transfers was moved by one person. The staff member doing the moving wasn't sure what the current guidance even was.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory floor, not the experience of sliding off a toilet seat onto a facility floor because the person responsible for moving you wasn't certain how much help you needed.
Resident 4's family member visits every day. She watched him transferred, sometimes with one staff member, sometimes with two, depending on who happened to be working. She had no reason to know that therapy had weighed in with a specific recommendation, or that the recommendation wasn't being consistently followed.
The DON's acknowledgment was straightforward: therapy said two people, and on the day of the fall, there was one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elm Crest Retirement Community from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 4, 2026 · Our methodology
Elm Crest Retirement Community in Harlan, IA was cited for violations during a health inspection on November 13, 2025.
The two of them got him there together.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.